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General NPI Number Information
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NPI Number | 1760828321
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Entity Type | Organization
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Legal Business Name | TINY TADPOLES BEHAVIORAL SERVICES, LLC
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Dates
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Enumeration Date | 05/21/2013
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Last Update Date | 05/21/2013
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Provider Practice Location Address
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Address Line | 14060 BIG CREST LN APT 403
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City | WOODBRIDGE
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State | VA
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Zip | 22191-5537
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Country | US
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Telephone | 570-713-9112
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Fax |
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Provider Business Mailing Address
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Address Line | 14060 BIG CREST LN APT 403
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City | WOODBRIDGE
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State | VA
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Zip | 22191-5537
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Country | US
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Telephone | 570-713-9112
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | RECAIRDO DEMETRIUS MANGRUM
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Credential | M.ED., BCBA
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Telephone | 570-713-9112
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State | VA
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